Nursing Documentation Made Incredibly Easy

This friendly reference guide provides clear-as-day guidance on meeting documentation requirements, working with electronic medical records systems, complying with legal requirements, and following care planning guidelines, helping nursing students and experienced nurses ensure timely, accurate, and watertight charting. It includes NEW and updated content, easy-to-retain guidance on using electronic medical records, and helpful charting examples.

\n Format: Paperback / softback
\n Length: 312 pages
\n Publication date: 31 July 2018
\n Publisher: Lippincott Williams and Wilkins
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This comprehensive reference guide is designed to assist you in meeting the various documentation requirements, effectively utilizing electronic medical records systems, adhering to legal requirements, and following care planning guidelines. Whether you are a nursing student or a seasoned nurse, this on-the-spot study and clinical guide will serve as your essential tool for ensuring timely, accurate, and comprehensive charting practices.

Packed with vibrant images and concise instructions, this user-friendly guide takes you step-by-step through the process of nursing documentation. It covers a wide range of topics, including:

Meeting Documentation Requirements: Learn how to document patient encounters accurately and efficiently, ensuring compliance with healthcare regulations and standards.

Working with Electronic Medical Records Systems: Gain insights into the effective use of electronic medical records (EMR) and electronic health records (EHR) documentation systems, including their features and functionalities.

Complying with Legal Requirements: Understand the legal implications of nursing documentation, including patient confidentiality, HIPAA compliance, and legal documentation practices.

Following Care Planning Guidelines: Learn how to develop and implement care plans that meet the individual needs of patients, incorporating evidence-based guidelines and best practices.

Enhancing Documentation: Discover strategies to improve the quality and completeness of your documentation, including the use of standardized language, clear and concise notes, and effective charting techniques.

Avoiding Legal Problems: Gain knowledge of common legal issues related to nursing documentation, such as falsifying records, negligence, and malpractice, and learn how to avoid them.

Documenting Procedures: Learn how to document medical procedures accurately and thoroughly, including the use of appropriate anatomical terminology and standardized abbreviations.

Documentation Practices in Various Settings: Explore the specific documentation requirements and practices in acute care, home healthcare, and long-term care settings, ensuring consistency and accuracy across different care environments.

Documenting Special Situations: Learn how to handle sensitive and challenging situations, such as the release of patient information after death, non-releasable information, and end-of-life care.

By following the guidance provided in this reference guide, you can enhance your nursing documentation skills, improve patient care outcomes, and maintain compliance with healthcare regulations. Whether you are a student or a practicing nurse, this resource will be your invaluable companion on your journey to excellence in nursing documentation.

\n Weight: 516g\n
Dimension: 178 x 228 x 12 (mm)\n
ISBN-13: 9781496394736\n
Edition number: 5 ed\n